Artificial Intelligence

Simulation exercises become an essential component of clinical education at SLU

SimMan 3G® can blink, sweat, cry, urinate and hemorrhage. His chest rises and falls, he produces lung, heart and bowel sounds. His right arm is so sophisticated that it can automatically recognize and respond to drugs and dosages.

And, if SimMan 3G® goes into sudden cardiac arrest and a nursing student injects amoxicillin rather than adrenaline, SimMan 3G® could die.

Linda L. Haycraft, M.S.N.(R), R.N., C.P.N.P., assistant professor and coordinator of clinical simulation at SLU's School of Nursing, where SimMan3G® helps train students, believes simulation education has proven its worth in many other occupations and is becoming essential to nursing education.

"If you boarded an airplane and the pilot said, 'Hi, I'm Linda Haycraft, and I'll be your pilot today. I've read all the books and heard all the lectures but I've never really flown a plane before. I hope you're OK with that,' how many would get off that plane?" she said. "We do the same thing with our patients. 'Hi. I've read the books and heard all the lectures, but I've never really worked on a patient with heart disease. Let me give you this medication.' We can do better than that."

Knocking Down Walls

Since assuming responsibility for SLU's nursing simulation laboratory four years ago, Haycraft has worked hard to create a state-of-the-art facility designed to bridge theory with practice. She surveyed faculty about the most common disease events nurses encounter - chest pains, congestive heart failure, dehydration, confusion, asthma - and designed simulations around them. Next, she started knocking down walls.

The School of Nursing expanded the lab on the first floor from one small room with two computers, an exam table and two manikins to what it is today - two hospital units, four exam rooms, 16 hospital beds and two control rooms where instructors behind one-way glass operate nine, moderate-to-high-fidelity manikins that simulate symptoms, diseases and conditions found in a real-care setting.

Teri Murray, Ph.D., A.P.H.N.-B.C., R.N., F.A.A.N., dean of the School of Nursing, said the expansion was an investment in SLU's students.

"Simulation allows our students to engage in real-life clinical experiences in low-risk environments," she said. "Our innovative approach enhances clinical competencies before students begin caring for patients in complex, high acuity patient care environments. By expanding the lab we've strengthened the educational process."

In the past, only juniors and seniors ran through simulations. Now, freshmen observe a simulation during their Introduction to Nursing course to get comfortable with the setting. Using pre- and post-operative manikins, sophomores learn to administer medications, insert catheters, and address the pain management and spiritual needs of patients. (Get more information about SLU's BSN programs.)

Eye for Detail

Before the exercise, students receive a packet of information containing the patient's history, suggested readings and a comprehensive list of learning objectives.

Once the students - no more than three per simulation - are at the patient's bedside, they speak to the manikin as though it were a real patient. The school installed voice modulators so faculty members behind the one-way glass who speak for the manikins actually sound like the patients, whether the patient is a 56-year-old man with coronary artery disease, a 5-year-old boy with asthma or an 84-year-old woman with heart failure and atrial fibrillation.

Although the basic scenarios are set, Cynthis S. Rubbelke, ('79, '85) M.S.N., R.N., a part-time instructor in the simulation lab for the past four years, said faculty sometimes alter simulations on the fly.

"It's just like the real world when things don't follow the plan," she said. "The ability to change course can expose students to a situation they might not experience in clinicals."

Behind each of the regulation hospital beds in the simulation lab is a head wall unit identical to those designed by the company that makes units for hospitals. Only the oxygen is inoperable. Everything else works exactly as it would in a patient's room.

Computers in each of the rooms are loaded with software that mimics the Epic medical record system widely used in hospitals. Students have Internet access in the simulation rooms to research medications or symptoms.

If still unsure, students can call for a nursing supervisor, a respiratory therapist or some other support staff for help. A simulation lab instructor will enter the room - in uniform and with the appropriate identification badges that Haycraft asked University security to create to lend even further authenticity to the simulations.

Watching the Clock

Simulations are done in real time with no shortcuts. If a patient with chest pains needs nitroglycerine, the student is expected to pull the correct medication and administer it within the recommended amount of time.

As fascinating as the manikins are, however, Haycraft said the de-briefing room is where most of the learning occurs. Ceiling cameras record all simulations, and instructors and students review the recording after the hands-on experience.

"The hardest is when a manikin dies," Haycraft said. "The students take it personally. They actually cry because they feel so bad. We don't talk about the material in their preparation packet at that point because they have to process their feelings. I remind them that this is where it's OK to make a mistake, and I'm certain they won't make that mistake again."

Things turned out better for Stephen Mackey, J.P. Moore and Kuna Chaekal, three seniors who recently completed their simulation exercise on "Johnny Miner," a 59-year-old retired coal miner with a heavy nicotine habit and COPD. They missed a couple of steps in the treatment process, but overall they (and their patient) did well.

"I like simulation because it gives us a chance to get used to hospital equipment and supplies before we have to deal with it in the real world," Moore said. "It's as close to real life as you can get without putting a patient in any danger."